HMO wants healthcare providers to be fair to patients
A Health Management Organisation (HMO), Sunu Health, says that no healthcare provider has the right to deny a patient primary care after being paid capitation for such services.
The Managing Director of Sunu Health, which was formerly known as Managed Health Care, Mr Patrick Korie, made this assertion in an interview with the News Agency of Nigeria on Saturday in Lagos.
He said that the National Health Insurance Scheme (NHIS) stipulated that primary care was paid for through capitation on a monthly basis.
Capitation is a payment arrangement for health care service providers.
It involves payment of a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
Korie spoke on the backdrop of complaints by some NHIS enrollees that they were refused treatment by health care providers on the grounds that their HMOs owe the hospitals.
Some enrollees, who claimed to be registered with Managed Health Care, now renamed Sunu Health, claimed that Gbagada General Hospital refused them treatment on the grounds that the HMO had not paid its outstanding claims.
The Managed Health Care boss, however, said that it did not owe Gbagada General Hospital.
“First, we do not owe General Hospital Gbagada any 2018 bill. If they claim we owe them, it will be appreciated if they bring evidence of the claim to our office for verification and payment if it is National Health Insurance Scheme (NHIS) claim and genuine.
“We at the HMO are always doing reconciliations with providers to ensure they are properly clarified on the issues of payment, as the NHIS scheme has a guideline for treatment and payment.
“That someone went to the hospital with his family and they were denied treatment and in another case declined giving them drugs for malaria is a very unfortunate incident as they are entitled to the treatments, which are primary care,’’ he said.
Korie said that primary care was paid for through capitation on monthly basis and its records showed that Gbagada General Hospital had been paid capitation to date.
The MD said that it would appreciate it if the patients brought the receipt of payment for services for Sunu Health to recover the money from the hospital.
“Please consult the NHIS operational guide for what is covered as primary care and the way the NHIS scheme works.
“We are not to pay for primary care to providers after paying them capitation. Such claims that are primary care are declined by the HMO according to NHIS guidelines.
“Providers document these as debts. This is the essence of reconciliation. It is also wrong for the provider not to contact the HMO to seek codes to treat or refer patients who require secondary care,” he said.
Korie said that referral was a primary care activity which was also covered by capitation, adding that the hospital never contacted it for codes to treat or refer the patients.
He said that it would be appreciated if the enrollee brought reports of non-treatment by a provider formally to the HMO for further action.
NAN reports that Managed Health Care had changed its name officially to Sunu Health in 2019.
At the Gbagada General Hospital, a senior officer who did not want his name mentioned said that Managed Health Care had paid their capitation fees up to date.
He said that there was, however, issue of service fees that had yet to be paid, but the hospital had not for once denied any enrollee treatment.
The official said that the drugs that were not given to enrollees were the ones not captured under the NHIS scheme.He said that the issue of service fees was an internal issue that would be resolved between the management of the hospital and Sunu Health.According to him, there have been discussions toward reconciliation.